Date *

MM

DD

YYYY

Date of Birth *

MM

DD

YYYY

What is the individual’s race?

American Indian or Alaska Native

Asian

Black or African American

Hispanic/Latino

White

Other

Has this child used the stock inhaler previously? *

Yes

No

Did the individual have a known asthma diagnosis before this day? *

Yes

No

Not Sure

Trained School Personnel’s Name *

First Name

Last Name

Time of day albuterol was administered: *

Hour

Minute

Second

AM PM

Disposition Status: *

Called 9-1-1 and transported via EMS

Called 9-1-1 and NO EMS transport

Sent home with parent / guardian / caregiver

Returned to class

Time EMS called (If Applicable)

Hour

Minute

Second

AM PM

Time EMS arrived (If Applicable)

Hour

Minute

Second

AM PM